If, as all the authorities recognize, the attitude of mind toward organic heart disease is extremely important and when favorable is a most helpful therapeutic factor, it is easy to understand that in neurotic conditions of the heart this is of even more significance. The term "heart disease" is bound up with so many unfortunate and persistently unfavorable suggestions that it seems advisable not to use it with regard to non-organic conditions, even though it may be associated with the epithets functional or neurotic. For these the term cardiac neuroses, which avoids the implication of heart disease in the ordinary sense, seems preferable. Many of the cardiac neuroses are quite trifling. Many of them endure for years without producing any serious effect or disturbance of the general health. Many functional disturbances of the heart action which are extremely annoying may disappear entirely with judicious regulation of life. The one important condition in all of these cases is to be sure that the patient does not worry over the condition, for that {322} hampers heart activity and leads to functional disturbances of other organs which make the heart's work harder.

Varieties.—There are many forms of cardiac neuroses. Indeed, functional heart affections are so individual that it is hard to classify them. In every case it is extremely important to study the individual and recognize just what are the special factors bringing about the disturbance of heart action.

Palpitation.—In a certain number of the cases it will be found, indeed, that there is no real disturbance, but that in some way the heart action has been brought above the threshold of consciousness and has become noticeable to the patient. It must not be forgotten that the heart is an intensely active organ. Several gallons of blood are pumped through it every minute and yet it accomplishes its work, as a rule, with such noiseless, frictionless regularity that most people know nothing about it. When the action of the heart becomes conscious, it is usually spoken of as palpitation. Patients are sure to think that this must mean serious over-action, though, as a rule, no sign of over-action or at most a slight exaggeration of the muscular sounds of the heart will be found.

Missed Beats.—A further stage of this cardiac neurosis is the missing of beats. This occurs particularly in those whose attention has been directed for some time to their heart action by the presence of palpitation. It may be due to nothing more than this over-concentration of attention. It may be due, however, to mechanical disturbances, an over-distended stomach, constipation, or certain nervous factors.

Arrhythmia.—A third stage of cardiac neuroses consists of irregularity of the heart action, in which not only are the beats missed occasionally, but there may be certain heart sounds much less vigorous than others and the spaces between the sounds may be very unequal. This condition is usually said to be due to some serious condition of the heart muscles, and undoubtedly it often is. There is no doubt, however, that great irregularity of the heart may occur entirely as a neurotic condition without any organic affection and from factors quite extraneous to the heart itself.

Etiology.—There are three causative conditions for cardiac neuroses that deserve careful study and that can be very much modified by changing the attitude of the patient's mind toward his condition. The first of these is an over-attention to self such as is particularly induced by a life without much exercise and devoted to things intellectual. The direct causation is probably intimately connected with the second etiological factor in the production of cardiac neuroses. This consists of an absence of sufficient exercise for the heart itself, when it actually seems to disturb its own activity because adequate calls for exertion are not made on it to use up accumulated energy. Cardiac neuroses are seen particularly in those who having had considerable exercise in earlier years, have settled down to a sedentary life in which there are few calls made upon their muscular system. The third etiological factor is the most important. It is due to cardiac disturbance from the stomach and intestinal tract; this will be discussed in a separate chapter.

Prognosis.—The prognosis in cardiac neuroses is always worse in the patient's mind than it ought to be. If then the physician shows that he is uncertain as to the real significance of the affection, some hint of this uncertainty will be communicated to the patient with resultant unfavorable suggestion. The {323} more carefully neurotic heart affections have been studied, the better the prognosis becomes. Morgagni in the olden time, Stokes and Corrigan in the early nineteenth century, Broadbent and MacKenzie in our time, have all emphasized the necessity for favorable prognosis. Even extreme irregularity is quite compatible with long life without any symptoms of serious circulatory disturbance. MacKenzie has, in his very careful studies of heart action, shown that extra systoles may cause marked irregularity in many forms without warranting unfavorable prognosis.

Arrhythmia may begin in comparatively early life, persist in spite of treatment, and yet continue up to old age. Sir William Osler tells of the case of the late Chancellor Ferrier of McGill University who died at the age of eighty-seven after having exhibited an extremely irregular heart action for the last fifty years of his life. He has seen several other patients who have had heart irregularity for many years without the slightest disturbance of their general health. His experience is not uncommon, and probably every physician who sees many cases of heart disease can recall a few of them. Ten years ago I saw a man past seventy suffering from distinctly irregular heart action, though he gave the history of having had cardiac irregularity for some years at least, and he is still alive, past eighty, and with his heart irregularity still present. I have a patient over seventy whom I know to have had irregular heart action for fifteen years, and he himself is sure that it has been present since he was about forty, at least. It is cases of this kind, together with MacKenzie's recent studies of the subject, that must be before the physician's mind when he makes his prognosis for these patients. There must be no hesitancy about his declaration. Patients think that physicians are prone to deny the significance of heart trouble so as to avoid disturbing their patients. The slightest hesitation, then, will be surely looked upon as of ominous import.

The Intellectual Life and Cardiac Palpitation.—It is curious how many people who give themselves to intellectual work and live an almost exclusively indoor life have subjective symptoms relating to their hearts. Many of the English literary men and women of the last century had complaints of this kind. Sir Walter Scott described very vividly his sensations as if his heart did not have room to accomplish its functions, and said that he used to feel within his chest a fluttering as if there were a bird there beating its wings against a cage too small for it. Other literary people have told of this sense of overfullness in the chest, as if somehow there were not room for all the organs. This discomfort is mainly referred to the precordial region. In oversensitive, nervous people it may be described as painful, though analysis of what they mean by the word pain will show that they have only a persistent feeling of pressure which is uncomfortable and gives a sense of crowdedness in that region rather than any genuine ache. Where the feeling is much dwelt on, however, it may be exaggerated into pain, as, indeed, will any sensation, however trivial, if attention is concentrated on it. On the other hand, in practically all of these cases, just as soon as the mind is strongly diverted by any pleasant occupation, the sense of discomfort disappears not to reappear again until the patient has time to think about himself.

Heart Surveillance.—Prof. Oppenheim of Berlin has in his usual direct way expressed the power of the mind to influence the heart beat, and he does {324} not hesitate to say that certain nervous people who have been watching their hearts overmuch, and continually thinking about them, are capable of playing all sorts of tricks on themselves and sometimes even on their physicians, by this concentration of mind upon their heart and its action. Prof. Oppenheim in his "Letters to Nervous Patients," writing to a patient complaining of irregular heart action, says:

Whenever you succeed in controlling the action of your heart by means of introspection, there flows from your brain to your heart a current of innervation which disturbs the automatic movement of the organ. You now know what you have to thank for the irregularity in the action of your heart. I have frequently proved this to myself in your case: if I succeeded in feeling your pulse without your becoming aware of it, holding your attention by a conversation which interested you, the action of your heart was always absolutely regular. If, however, I tried it under your control, while your attention was anxiously directed to your heart, its action at once became irregular, and you experienced the very unpleasant sensation of palpitation.

Irritable Heart of Athletes.—A curiously interesting form of heart neuroses has appealed to me very much because I have suffered somewhat from it myself and owing to circumstances I think I have seen a larger number of patients suffering from it than usually come to a single individual. I refer to the tendency to irritability of the heart which is so marked in men who have been athletes when they were younger, and have taken a large amount of exercise during the years between fifteen and twenty-five. If these men later settle down to a sedentary life they almost inevitably suffer from a marked sense of discomfort in the precordial region because of palpitation, and are apparently much more liable than other people to have an intermittent pulse. Just what these symptoms are due to is not always easy to discover, and in different individuals there seem to be different accessory causes at work. I have seen it particularly in professional men who while at college have been on the teams and have played such hard games as handball, hockey on the ice, and the like. I do not refer only to those who have played an occasional game, but who every day of the college year have had some severe muscular exercise.

Whether this irregularity of heart action has not at least been predisposed to by over-exertion remains to be determined. Strenuous athletics produce curious heart symptoms. Missed heart beats and irregular heart action and even leakages at the valves are not unusual even in the best of hearts after severe exertion. A careful examination of the hearts of those who took part in a Marathon run at Harvard some years ago showed that immediately after the race many of them were irregular and some of them had leakages at the mitral valve which lasted from one to twenty-four hours. These were probably due to irregularity in the action of the papillary muscles as a consequence of the fatigue. I had occasion to examine the hearts of some theatrical dancers a few years ago, immediately after they came off the stage. One of them is one of the most successful of modern dancers and is able to occupy the better part of an hour in the severest kind of exertion before an audience. Her heart was not only very rapid immediately after she left the stage, but there were missed beats and a distinct disturbance at the mitral valve. It was hard to determine absolutely, but the sounds at all the valves were impure and there {325} seemed to be imperfect closure or irregularity of action. In another case there was a regular missed beat at every sixth or seventh pulsation. This seemed to be due to an abortive systole. Usually within an hour regularity of heart action is restored and the valve sounds become normal. At times when the patient is run down for any reason, the cardiac disturbance may persist for many hours, or even until after long hours of sleep.

The patients I have mentioned seem to have developed their muscles to a noteworthy degree and have enlarged and strengthened their hearts by this exercise. Later on their occupation in life prevents them from taking any severe exercise, or at least furnishes no opportunity for it, and they often settle down to existence that, beyond a short, quiet walk perhaps once a day, affords no exercise at all. Under these circumstances the muscular development that they secured as young men and which kept them in such magnificent health during their adolescent years seems to prove a positive detriment to good health, or at least to good feeling. The muscular system seems to crave to be kept up. Occasionally I have been sure that the intermittent heart action so often seen in these cases was due to the fact that the appetite, or as I should rather put it, the habit of eating, which they formed while they were accustomed to taking vigorous exercise, remains with them during their sedentary life and as a consequence they overeat, particularly of proteid food materials. The large consumption of these materials gives rise to the presence of substances in the blood which make all the muscles more irritable than usual, and this seems to add particularly to the irritability of the heart.

Dietetic Regulation.—For many of these people a regulation of diet seems to be the best possible remedy. They must be made to eat less substantially, since they do not need the same amount of proteid material to make up for muscle waste, now that there is no longer the old use of muscles. Some of them become very heavy. These, however, are mainly individuals who, besides eating abundantly of proteids, also consume carbohydrates in large quantities. In these there is a distinct disturbance of digestion and a tendency to dilatation of the stomach with gas which interferes with the heart action and brings on the intermittent pulse so often seen in them. In a certain number, however, there are no accessory symptoms of indigestion, but the heart symptoms are most prominent.

Exercise.—For these people the only real relief is afforded by a certain amount of exercise every day. They become ever so much more comfortable just as soon as their physician insists that they shall have an hour's walk at least every morning and every afternoon and that this walk shall be brisk and always have some definite purpose in it, so that there is no mere sauntering or delaying on the way. Most business men to whom this prescription of an hour's walk is given will reply that it is impossible. Most clergymen will say that their duties are such that they cannot arrange their hours for this purpose. As a rule, it is not difficult to show the business man, however, that if instead of riding to his business, he should walk every day, and this will probably only take twenty minutes to a half-hour longer than if he goes by trolley or even by automobile, this walk will provide him with a full hour of brisk exercise in the open air. The walk back from business will provide the other hour, whenever golf or some other diversion cannot be provided instead. In most cities men live from three to five miles away from their {326} business, and it is not too much to ask them to take this walk. The muscular clergyman must be made to understand that there shall be no trolley cars for his ordinary clerical calls, or at least that none are to be taken unless he has had his full two hours of brisk walk.

There is always the fear in the patient's mind that exercise, by calling for heart exertion, is almost sure to make the condition worse. This fear of itself further hampers heart action. When exercise is first increased in those who have been living sedentary lives the heart action for a time is brought more and more into the sphere of consciousness and any irregularity that is present is likely to be emphasized. A little persistence, however, soon shows that what the heart actually was craving was the opportunity to expend some of its energy and it was this pent-up force that was disturbing its action. There is often the fear in physicians' minds lest the advising of exercise should really do harm to the patient. They fear the presence of perhaps a fatty condition, or of some obscure muscular condition, or of some other heart lesion not easy to detect, yet likely to produce serious symptoms. Stokes, who probably knew fatty heart disease better than anyone else in the nineteenth century, outlined his views of the therapy of it as follows:

In the present state of our knowledge the adoption of the following principles in the management of a case of incipient fatty heart disease seems justifiable:
We must train the patient gradually but steadily to the giving up of all luxurious habits. He must adopt early hours, and pursue a system of graduated muscular exercises; and it will often happen that, after perseverance in this system, the patient will be enabled to take an amount of exercise with pleasure and advantage, which at first was totally impossible, owing to the difficulty of breathing which followed exertion. This treatment by muscular exercise is obviously more proper in younger persons than in those advanced in life. The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, such as Switzerland or the Highlands of Scotland or Ireland. We may often observe in such persons the occurrence of what is commonly known as "getting the second wind," that is to say, during the first period of the day, the patient suffers from dyspnea and palpitation to an extreme degree, but by persevering, without over-exertion, or after a short rest, he can finish his day's work and even ascend high mountains with facility. In those advanced in life, however, as has been remarked, the frequent complications with atheromatous disease of the aorta, and affections of the liver and lungs must make us more cautious in recommending the course now specified.

Perhaps the most important therapeutic suggestion which Sir William Broadbent has to make with regard to the cardiac conditions that have come to occupy much of the patient's attention is of a negative character. He says that "patients suffering from these functional derangements of the heart usually make them a pretext for avoiding exercise and often for taking stimulants or drugs, whereas exercise and fresh air are what they need. The best way to prevent the expenditure of superfluous energy on the part of the heart in the form of palpitation is to give it a fair amount of legitimate physiological work to do." Personally I have found that most of the cardiac tonics seem to do harm, in the sense of increasing the subjective symptoms, except in cases where the patient is run down in general health because of failure to take sufficient food, when strychnin seems to be of avail and in the shape of nux vomica acts as an appetizer as well as a heart tonic. Sir William Broadbent has warned particularly with regard to the use of alcohol in these cases. {327} Most patients find that for the moment palpitation is lessened by alcoholic stimulation. They pay for it afterwards, however, by an increased sense of discomfort that sometimes lasts for 24 hours or more. As Sir William Broadbent declared, "To relieve one attack of palpitation or fainting by alcohol is to invite another, while the terrible danger of dropping into alcoholism is incurred."

Lest it should be thought that even Broadbent is a little old-fashioned and not quite to be trusted in the light of our present-day knowledge, and above all lest it might be feared that these older men made a better prognosis or emphasized the value of exercise more than is compatible with our recent discoveries in the physiology and pathology of the heart, it seems well to give MacKenzie's opinion of these cases in full. This is all the more important because, as I have said, the influence of German teaching has led to the formation of rather different opinions in America, especially among our younger physicians. Prof. Martius in this country in his lecture for the Harvey Society gave quite a serious prognosis for practically all heart irregularity. He almost went so far as to lay it down as a rule of diagnosis that whenever a heart beats irregularly there is something the matter with the heart muscle or good reason to suspect a myocardial lesion of some kind. MacKenzie's view is very different to this and he warns particularly against permitting the influence of an unfavorable attitude of mind on the part of these patients. He says:

The most serious thing about these cases is that the consciousness of having an irregularity sometimes makes a patient introspective and depressed. He keeps feeling his pulse, and communicates his doleful tale whenever he find a sympathetic ear.
As the process which gives rise to it in elderly people is the same as that which produces the tortuous temporal arteries, no more significance should be attached to the one symptom than to the other. I have followed cases for many years, and watched them pass through seasons of sickness and of stress, and have seen no reason to attach any serious import to this symptom. In rare instances the heart, from being occasionally irregular, has after many years become continuously irregular for short or long periods, and in a few the permanent establishment of the nodal rhythm has been the means of hastening the end. But this is infrequent, and in cases of cardio-sclerosis has only happened in advanced life, and the patient should on no account be frightened by being warned of the possible occurrence of this unlikely contingency. In younger and neurotic people I have never seen it lead to any bad results. It may appear in serious affections of the heart, as in febrile complaints, but it does not of itself add to the gravity of the condition, though I am not sure that when due to an acute infection of the heart, as in pneumonia and rheumatic fever, it may not be a sign of invasion of the myocardium by the diseased process.
If the patient is aware of the irregularity, he should be assured that there is no cause for alarm. It is useless to attempt to treat the irregularity itself. If in other respects the patient is well, then there is no need of any special treatment. If the patient be suffering from conditions which seem to promote irregularity, such as worry, fatigue, dyspepsia, the treatment should be devoted to the removal of the predisposing cause. In people with temporary high blood pressure, who show extra systoles, I find plenty of healthy exercise in the open air specially beneficial, though until they get trained, the extra systoles may at times become more frequent by the exertion.

This last remark of MacKenzie's is particularly important, for at the beginning of an attempt to relieve the symptoms by insisting on more {328} exercise, the patient is almost sure to be disturbed by this symptom of which he will often be conscious, and it takes a good deal of experience on the part of the physician to reassure him that because of the increased subjective symptoms at the beginning of the treatment by increased exertion, he may not be doing harm rather than good. As a rule, however, it is not long before the good results of the exercise treatment of these cases begin to make themselves felt and the patient is reassured. Regulated exercise of body and occupation of mind are the two important factors even in the treatment of organic heart disease. They are extremely important even in the cases with alarming heart symptoms that occur in the very old, once the acute symptoms have subsided. In all the functional heart affections exercise is the most important therapeutic resource we have. It would seem that in the course of muscular exercise some heart tonic was manufactured, which in all but the cases of absolutely failing hearts is the best possible therapeutic resource for the stimulation and steadying of the heart action. Such an internal secretion would not be surprising in the light of all that we have learned of the physiological nexus of organs in recent years.

Many so-called cures for heart disease probably depend for their good effect much more on the graduated exercise that goes with them than on many of the other remedial measures, though it is these latter that are usually vaunted most highly. We all now recognize how little value there is in the Nauheim bath treatment for heart disease away from Nauheim itself. The reason is because the resisted movements of the early part of the cure and, above all, the graduated exercise of walking up the hills around Nauheim, which are such important parts of the treatment there, cannot be so well given with the baths at a distance.